The global public health crisis caused by smoking tobacco

Death and disease

The facts are stark.

The World Health Organization (WHO) estimates that one billion people will have died from tobacco-related diseases by the end of this century.

That is roughly equivalent to the entire population of North and South America, or 13 per cent of the current global population.¹

Each year, over seven million people die from diseases related to tobacco use – more than from malaria, HIV and tuberculosis combined.

Smoking is the single biggest cause of non-communicable disease (NCD) worldwide.

Half of all those who smoke will die prematurely and painfully due to diseases directly related to an extraordinary range of illnesses, from cancers of the lung, throat, pancreas, bladder, stomach, kidney, or cervix, to heart attack or stroke. Loved ones suffer these losses too.

Many millions of people worldwide also experience years of disability and reduced quality of life due to diseases such as chronic obstructive pulmonary disease (COPD), macular degeneration, cataracts, diabetes, fertility problems and rheumatoid arthritis, which are all caused by, linked to or exacerbated by smoking.

Smoking also directly impacts on bystanders. The WHO estimates that a third of all people around the world are regularly exposed to the effects of tobacco smoke. This exposure is estimated by the WHO to be responsible for about 600,000 deaths per year, and approximately 1% of the global burden of disease worldwide.²

Economic impact

Trying to establish the precise economic impact of smoking on the global economy is difficult. However, in 2017, the WHO and the US National Cancer Institute published a study which estimated that the worldwide healthcare cost of smoking in just one year (2012) was $422 billion, which would account for 5.7% of all global health expenditure. Estimated indirect costs totalled $357 billion for morbidity and $657 billion for mortality. The total annual economic cost of smoking was therefore estimated to be $1.4 trillion, or 1.8% of the world’s annual GDP.³

Who smokes?

It’s estimated that 1.1 billion people smoke tobacco every day, of whom it is thought 80% live in low-and middle-income countries (LMIC).⁴

In many higher income countries, levels of daily adult smoking have fallen since the early 1970s and are now ‘low’ as defined by international standards, meaning under 20% of the population smoke. This is largely due to greater public awareness of the importance of a healthier lifestyle and the introduction of tobacco control measures (including advertising bans, smoke-free environments, availability restrictions and higher taxation).

1.1 billion people smoke tobacco every day; 80% live in low- and middleincome countries

But in many higher income countries, smoking rates have now begun to level off: substantial numbers of people continue to smoke. In these countries, levels of smoking, and consequently smoking-related death and disease are disproportionately high among vulnerable and marginalised groups, including people living in poverty, from minority ethnic or indigenous communities, from the LGBTQ+ community, people living with mental health conditions or with substance use problems.

Many low and middle-income countries (LMIC) are not sufficiently resourced to implement and enforce tobacco control policies. The situation is further complicated in countries where the economy is reliant on income from tobacco cultivation. Levels of smoking in many LMIC are plateauing (and may be under-reported). Numerous LMIC have large projected population increases, suggesting the number of smokers is likely to rise.

smoking-related death and disease are disproportionately high among vulnerable and marginalised groups

One target of the overall UN Sustainable Development Agenda (SDA) is to reduce premature deaths from non-communicable disease by one third by 2030.⁵ The top three causes of NCD mortality are cardiovascular disease, cancer and respiratory disease – all of which are closely associated with cigarette smoking. It is hard to see how this goal can possibly be achieved if dramatic reductions in smoking are not achieved.

“People smoke for nicotine but they die from the tar.”

As pioneering tobacco researcher Professor Mike Russell identified in 1976, “Smokers cannot easily stop smoking because they are addicted to nicotine…. People smoke for nicotine but they die from the tar.”⁶

People smoke tobacco because they feel they benefit from the effects of nicotine. People report that it helps concentration and can relieve anxiety or stress. Conversely, people who smoke say they crave cigarettes, feel agitated and irritable and find it hard to concentrate if they run out. From this point of view, some people are said to be dependent on nicotine. But given that nicotine as a substance is relatively benign and does not cause any of the illnesses associated with smoking, using nicotine is arguably not the physical or psychological problem usually conveyed by the public image of the word ‘addiction’.

It has been clear for many years that the reason people die prematurely or develop life-threatening diseases from smoking cigarettes is exposure to the toxic chemicals released when a cigarette is lit and the fumes from burning are inhaled. The main toxins in cigarette smoke identified as potentially harmful include carbon monoxide, volatile organic compounds, carbonyls, aldehydes, tobacco-specific nitrosamines and metal particles.⁷ Over 70 of the 7,000 – 8,000 chemicals released in the combustion of tobacco are carcinogenic.

Nicotine, the drug for which people to continue to smoke, is not a carcinogen. Nor is it harmless – no substances are. But the clinical evidence suggests that at “commonly used dose levels, short-term nicotine use does not result in clinically significant harm.”⁸ Studies of nicotine replacement therapy (NRT) products, such as patches, gum, inhalators, tablets/lozenges or nasal/oral sprays containing nicotine, have demonstrated this. Long-term, it is more difficult to know, as studies to date have mainly relied on nicotine obtained through smoking tobacco. But, according to the UK Royal College of Physicians, “it is widely accepted that any long-term hazards of nicotine are likely to be of minimal consequence in relation to those associated with continued tobacco use.”⁹

The risks nicotine poses to human health are minute compared to those posed by its most commonly used delivery system, the tobacco cigarette.

The majority of smokers want to quit smoking and many thousands do so successfully every year. Some manage to quit by themselves. In countries where they are accessible and affordable, some people use NRT products, or medications such as varenicline or bupropion. Many smokers have very many unsuccessful quit attempts before finally managing to quit indefinitely.

For many, using NRT or medicines does not work. The reasons for this will be as individual as the person who wants to quit, but may include the failure of these products to replicate the ritual aspect of smoking and the lack of a sufficient nicotine experience.

Tobacco control

The primary piece of international legislation concerned with tobacco control is the Framework Convention on Tobacco Control administered by the WHO, which encourages FCTC delegate countries to adopt the following strategy:

Monitor tobacco use and prevention policies
Protect people from tobacco smoke
Offer help to quit tobacco use
Warn about the dangers of tobacco
Enforce bans on tobacco advertising, promotion and sponsorship
Raise taxes on tobacco

In higher income countries, the so-called MPOWER model has been in place for years. Most recently, these have included increasing numbers of public smoking bans. These measures have helped to bring down adult daily smoking rates. But rates among people who are vulnerable or marginalised due to poverty, sexuality, ethnic minority or indigenous background, mental health diagnosis, involvement with the criminal justice system or use of illicit drugs or alcohol remain consistently high.

Raising cigarette prices has helped to reduce smoking rates. However, the strategy has a regressive effect, namely, increasing economic inequality, given that both smoking rates and the number of cigarettes smoked each day are higher among people from lower socioeconomic groups.

Moreover, public anti-smoking campaigns have embedded feelings of guilt and shame in people who, for whatever reason, continue to smoke. Research has shown that the stigma attached to smoking can prevent people from seeking help if they are unwell. For lung cancer patients, for example, this can lead to delayed diagnosis and poorer prognosis, lower quality of life, negative impacts on relationships and interactions with health workers.¹⁰

public anti-smoking campaigns have embedded feelings of guilt and shame in people who, for whatever reason, continue to smoke

Stigma creates additional suffering on an individual level. However, it can also reinforce population health disparities, impacting most significantly on those who are already the most vulnerable. Some argue it should not be used as a strategy in global health at all.¹¹

The war on tobacco becomes a war on nicotine

Many advocates for tobacco control see worldwide abstinence from tobacco use and the dismantling of the tobacco industry as the only viable measure of success. Tobacco control has become a war on tobacco.

In taking a total prohibitionist stance on tobacco, tobacco control advocates are also waging war on nicotine. In doing so, they may be missing the most significant public health opportunity the world has ever seen.